Prostate Health Conference 2011: Prevention & Screening

MD Anderson Cancer Center
Date: January 2012

>> And then we'll try to make the best of all that so let's get going with our two featured speakers.  Therese Bevers is in the Department of Medicine under cancer prevention and she's gonna give us the big picture of cancer screening not just prostate but the whole program.  So, Therese?

>> Thank you.

[ Noise ]

>> Okay.

>> Let's--can I do that for you [inaudible].

>> Looks like they are.

[ Inaudible Remark ]

>> Okay, very good.  Well, thank you for this opportunity to be here.  Yes, I had been invited in the past years and regretfully couldn't make it so I'm very excited to be here because I think this is a wonderful opportunity to share information and for me to get to talk to you about cancer screening.  And as Dr. Davis was saying it's not just about prostate screen.  I want to talk to you kind of about the whole spectrum of cancer screening and I will even address some of the few women in the audience as well.  So, one of the first question is why screen for cancer?  Well, it's fairly well established that for many cancers if we catch it at an earlier stage, it is more treatable.  We can use less toxic therapies and the outcomes are better so we want to find those cancers at the earliest most treatable stage. 

We have seen progress being made against cancer.  This is the slide just on American men but we see similar parallels to women in many respects.  Where we had initially seen an increase in lung cancer due to cancer prevention efforts in tobacco cessation we now are seeing a decline in lung cancer deaths in men.  We started to see that turn in women although I don't have that slide.  You see that prostate cancer here has been decreasing in the number of deaths as well as cancer of the colon and rectum.  This particular slide here looks at trends in five year survival rates for both men and women and I think this is a very exciting slide to see.  If you look compared to the 1970s, more people are surviving cancer.  Almost two thirds of individuals who were diagnosed with cancer will survive their disease.  We see that cancer of the breast has improved in survival so has cancer of the prostate.  We can see that colon and rectum down here and even leukemia, all of these less likely, individuals diagnosed with these cancers are less likely to die of the disease.  Now, it's a combination of factors that has contributed to that.  It's not all cancer screening.  Certainly, we have improved treatments. 

But for many of these like breast, prostate, colon and rectum, we have screening test that can afford the earlier detection of cancer and improve the outcomes.  It has been estimated that as many as one half of cancer death could be prevented by cancer screening and so you see at the pearly gates it says, "I would have been here sooner if it hadn't been for early detection."  That's kind of our goal is, to make sure that we can maximize early detection to improve the outcomes.  But there are reasons not to screen an individual.  There are some rare cancers that are so rare that they affect a very, very tiny portion of the population.  The cancer may not cause significant illness or death and, for example, like the basal cell carcinoma.  It doesn't tend to cause death and it's pretty straight forward in its treatment so we don't, for many, need to be doing screenings for it.  In some cases, earlier diagnosis doesn't lead to a better outcome. 

For lung cancer, that's been the history we've had as we hadn't been able to catch lung cancer at an early more treatable stage but I've got some exciting news for you in a little bit to tell you on that.  And in some cases, there is no effective treatment and there's not really a good reason to be looking for a cancer if we don't have something to offer you to treat it.  So, who should be screened?  Well, first off, let me just kinda back up and give you the definition of what screening means.  It's looking for disease in someone who has no symptoms.  One of the most reason, most common reasons I am told that an individual doesn't want to undergo screening is, "But I don't have any symptoms."  Well, that’s exactly the population we want to screen.  If you already have symptoms, it is no longer screening tests that we use.  It is diagnostic test.  Trying to figure out what is causing your symptoms.  So the first and most important thing is its asymptomatic individuals.  We also want to be screening someone who's gonna have enough time to benefit from cancer screening so we typically talk about a 10 year life expectancy.  So for someone who has end stage heart disease and their life expectancy is maybe only a few years from their heart disease, they probably not gonna benefit a whole lot from cancer screening.  Additionally, if they have significant comorbidities, they may not be able to undergo the treatments that we would have to offer or maybe not even able to undergo the workups that we would recommend for abnormal screening test.  Additionally, an individual needs to have decided before they undergo screening.  If we find something on this test, I not only want to undergo the evaluation of that finding but then also understand what my treatment options are and seriously consider those.  If you're saying, I don't know that I will do anything if you find something on that screening test, let's not look.  So, cancer screening is no longer one size fits all.  We now base cancer screening on a person's individual cancer risk.  To understand what kind of screening test are appropriate for you, the starting point would be to understand what is your cancer risk and we look at several different areas related to cancer risk. 

First off, your own personal health history; there are some medical conditions that can increase your risk of developing cancer.  For example, inflammatory bowel disease increases the risk of colon cancer.  Having a history of colon polyps that are precancerous increases your risk of colon cancer.  If you have an HPV infection, human papillomavirus, that can increase your risk for a number of cancers: cervical, and oral, and anal, and penile.  So, knowing these risks help us to indentify who is at increase risk and may need additional or more frequent screening.  Additionally, a cancer survivor is at increase risk of a second primary cancer.  In other words, a totally new cancer, generally unrelated to the first although in some cases it may be related to a common genetic link or even to the treatment that we offered for the original cancer. 

Certainly, having a family history of cancer puts an individual at increase risk especially if they have indentified mutation in cancer causing genes and there are several of those genes that have been identified such as for breast cancer.  Many of us have heard about B-R-C-A or BRCA.  There's also genes for colon cancer and others.  Racial and ethnic background can increase your risk.  I think probably a lot of the men in the room are familiar that African-American men are at higher risk of developing prostate cancer.  Hispanic women are at higher risk of cervical cancer.  Ashkenazi Jewish women are at higher risk of breast cancers.  So, these are all factors that we want to consider in understanding what an individual's cancer risk is.  We have developed a cancer risk check and it's on the MD Anderson website.  If you go to mdanderson.org/riskcheck, you can go in and answer a series of questions and it will help you to understand what your cancer risk is and what cancer screening test we would recommend based on that individual level of cancer risk.  So, cancer screening test are performed as I told--said before when the patient is asymptomatic.  In other words, they're healthy and don't have any symptoms.  It's important for you to talk to your doctor about your cancer risk so that they can lay out a cancer screening plan for you, individualize it based on your risk.  If you're average risk for one cancer, you may go with what you commonly hear as the cancer screening recommendations.  But if you're at increased risk, he may recommend something vastly different than what you've ever heard of before.  Your doctor can also talk to you about the benefits of cancer screening, largely what we've talk about early detection.  Can also talk to you about some of the risk and harms such things as false positives where the areas of abnormality that after workup doesn't turn out to be anything.  Over diagnosis where maybe it's a cancer that will never become a clinical problem for that individual in their lifetime.  That's one of the issues that we have struggled with in prostate cancer is understanding which prostate cancers are gonna be clinically significant and which ones won't.  So it's important to talk to your doctor about that.  I want to just quickly run through our cancer screening guidelines or recommendations and these are for average risk individuals.

>> So, remember, if you're thinking, "Oh, I have a family history of this or I have a personal history of that," what I'm going to discuss with you right now may not apply and that's why it's important to talk to your doctor.  And like I said I would give the women in the audience a little bit of information and this is it.  Actually, women have more slides on cancer screening.  I think we have to undergo more screening than the men do, but anyway for women between age 21 and 29, we recommend a breast exam by a clinician every one to three years and have a Pap test.  We at the MD Anderson recommend the liquid-based Pap test which is a little bit easier for the pathologist to read, to see if the cells are abnormal and she only needs to do it every two years. 

We no longer recommend a Pap test for any average risk woman to be done every year.  Now, high risk woman may need it every year but average risk woman between the age of 20 and 29 only needs it every two years.  For women 30 to 39, again, the clinical breast exam is the same but now beginning at age 30 we recommend in addition to the liquid-based Pap test we recommend HPV testing or testing for that human papillomavirus that can cause cervical cancer and the combination of those two, if they are both negative and you have no other risk factors, then a woman needs a Pap and HPV test only every three years.  For women age 40 and over, at 40 we recommend that she begin to get annual breast exams and mammogram.  A breast exam and mammogram every year; continue with that liquid-based Pap and HPV test every three years.  And then beginning at age 50 get a colorectal cancer screening with colonoscopy is one of our preferred options.  Colonoscopy only needs to be done every 10 years. 

or men, we typically encouraged them to talk to their doctors beginning around the age of 40 to understand their risk.  We recommend that they have a baseline or a digital rectal exam and PSA at age 45 if they are at increase risk.  In other words, African-American men or men with a family history of prostate cancer.  Beginning at age 50, it's an annual digital rectal exam and PSA blood test and then same as women a colonoscopy every 10 years. 

ow, as I discussed at the beginning about screening test, it's important to talk to your doctor about the benefits, the risk and limitations of cancer screening and we've always heard that or for many years have heard that about prostate screening but really that should apply to all cancer screenings.  You shouldn't just jump in and do it.  It's understand what your risk are, what kind of benefits you're gonna get and then make sure you wanna do something about it. 

So, I want to spend the last few minutes talking about a couple new cancer screening test that you may not be as familiar with.  We're always looking for ways that can offer us different ways to find a cancer or new tests to screen for a cancer that we haven't been able to screen for before.  One of them that we now are able to offer is virtual colonoscopy.  Now, virtual colonoscopy is where we use a CT scan that takes thin slices in the imaging and they are able to create a three-dimensional picture of the colon and that's what they call it virtual because that computer is involved.  You can see the difference here.  Optical colonoscopy is the traditional colonoscopy what we commonly think of is when they insert the lighted tube in the rectum, go up in the colon and look for polyps.  And in fact, you can see here at this arrow, here is the polyp right there.  That's on the traditional colonoscopy.  Here is the virtual colonoscopy on the same patient and here is the same polyp.  Now, there's benefits and limitations to each of these tests.  The benefit to optical colonoscopy is while the doctor is in there with that colonoscope and sees that polyp, he can biopsy it and remove it right then.  But the test is a little bit uncomfortable so you need to be sedated to have the test and because you were sedated, that means that you need to have someone there with you to drive you home which sometimes can be a little bit of barrier if you don't have someone that wants to take off work to be driving you to the doctor.  We can get around that with virtual colonoscopy.  You are awake during the entire procedure so you do not need anybody to drive you to get this testing done.  One of the limitations of it is, when we do see this polyp, we're not able to remove it so then you have to flip over to get the optical colonoscopy or the traditional colonoscopy. 

Now, both of these tests require an individual to undergo the prep which if anybody in the room has had a colonoscopy, I think we all agree that's probably the worst part.  And one of the things we're trying to do at MD Anderson, we offer virtual colonoscopy and one of the things we're trying to do is set up a parallel program between traditional colonoscopy and virtual colonoscopies.  If we're doing a virtual colonoscopy and we see that polyp, to save you from having to undergo another prep we have gastroenterologists that will try to work you in that day or worse case scenario the next morning first thing to snag that polyp out so that you don't have to repeat the prep.  Same thing if we're doing the traditional colonoscopy and it starts getting very difficult and they're not able to get around the whole colon, they can flip you over to do the virtual colonoscopy so that we can image the entire colon and make sure that it's clear. 

This is a very exciting option for individuals, the virtual colonoscopy, because 90 percent of individuals who undergo a colonoscopy don't have a polyp.  So that means 90 percent of people we say, you're great, you're fine, go home, come back in five years, we actually only give you five years if you did the virtual colonoscopy as opposed to 10 years with the traditional colonoscopy.  But 90 percent of the people we don't have to worry about moving on to the traditional colonoscopy.  So, for 90 percent of the people they were able to drive themselves there, get the test, be told its okay, and go home.  Ten percent will still have to undergo the additional testing.  A limitation currently of the virtual colonoscopy is the limited reimbursement.  It is not currently covered by Medicare and there are only a limited number of payors that will cover virtual colonoscopy for screening.  So, we're not seeing a lot of utilization yet.  I anticipate that once Medicare picks that up, other payors will pick it up and more individuals will have an interest in virtual colonoscopy. 

You can see the American Cancer screening recommendations for colorectal cancer and MD Anderson has the same.  We actually have divided the colon cancer screening into two different types of tests, tests that find mainly cancer.  In other words, it’s may be not as early a detection as we would like and that's your fecal occult blood test cards, the reason being a lot of polyps don't bleed.  It may have to actually be a cancer before it starts to bleed.  The FIT test, the Fecal Immunochemical Test, is a similar to the FOBT.  It's a stool card test.  And then there is a stool DNA test.  Those again may not be the earliest detection.  These tests on the other side are tests that not only find cancer but can also find the precancerous stage colon polyps.  And so those are preferred cancer screening tests and the ones that we do prefer at MD Anderson are the colonoscopy every 10 years or the CT colonography which is the virtual colonoscopy every five years.  Because if those--those individuals we can find polyps and remove it.  But it's exciting to be able to have new tests to offer individuals so that they have more options for colorectal cancer screening. In fact, it's been suggested that as many as 90 percent of colon cancer deaths could be prevented if individuals would get their colon cancer screening so we need to get people to be taking advantage of these tests. 

One other new screening test on the block that we're very excited about, this just came out in the past couple of months.  For many years, we have known that lung cancer was a killer.  Once you were diagnosed with lung cancer, it was too late.  We didn't have any screening test where we could find this cancer at an earlier stage where we could change the outcome.  However, since the early part of around 2000-2001 we started a trial called the National Lung Screening Trial or NLST done here in the  United States and MD Anderson was a participant in this trial and over 53,000 individuals who were at high risk of lung cancer were enrolled.  They were at high risk because they had over a 30-pack-year smoking history.  Pack years is the number of packs times the number of years multiplied together so maybe they were a one-pack a day for 30 years or a two-pack a day for 15 years.  These individuals were aged 55 to 74 and they were randomized or put into different groups to get either an annual chest x-ray for three years or this thin slice CT scans.

>> Same as what we're doing in the virtual colonoscopy, same type of thin slice CT scan.  They get it annually for three years and then we followed them for an additional 7 years for a total of 10 years.  And just this July, the results were announced and published.  We saw that they were fewer cases of lung cancer deaths in the individuals who got the CT scan of the lungs than in the individuals who got the chest x-ray.  In fact, the death rate was 20 percent lower in those individuals.  Twenty percent may not sound like a lot but that is huge.  That's fairly comparable to what we see with mammographic screening and we know that because of mammographic screening fewer women are dying from the disease.  We're very excited now to have lung cancer screening to offer individuals who are at increased risk so maybe we can catch that disease earlier when it's more treatable. 

Of course, the most important thing is if you're a smoker, quit smoking and if you're not, don't start.  But certainly, for those who have already incurred the risk being able to offer them something to catch a deadly disease earlier so it may be not deadly.  Again, this is a new screening test and is not yet has been picked up by Medicare.  It will probably undergo review by Medicare in 2012.  We're optimistic it will become a coverage service and, again, once Medicare picks it up as a coverage service, we expect to see other payors follow it along.  MD Anderson does offer lung cancer screening but right now it's a self-pay service.  So it's, again, fairly limited but I think that we've tried to put it out at a fairly reasonable rate when you consider that it's a CT scan; it's 400 dollars for the scan, the interpretation, and the like.  Still, we would really like to see it covered by payors and hopefully we'll get more utilization when that occurs. 

So that's kind of an overview of cancer screening.  I wanted to mention to you that we have cancer screening guidelines at MD Anderson that we have developed.  And these cancer screening guidelines are what I've talked about here which are for average risk but I think one of the very unique aspects about MD Anderson’s cancer screening guidelines is we also talk about what you should do if you're at increased or high-risk of cancer and we have these screening recommendations at mdanderson.org/screeningguidelines.  And again, we provide recommendations for individuals at different risk levels. 

Now, let me show you kind of the backbone of what we do.  These are the algorithms that I and some of the expert clinicians in the institution put together and so I just happened to pick out the colorectal cancer one.  You can see here, this particular page is for individuals at average risk and we have defined what average risk is, 50 years of age, you haven't ever had a precancerous colon polyp or an adenoma, you don't have inflammatory bowel disease or a family history and it talks about the preferred screening test, as I mentioned, the colonoscopy and the CT colonography. 

But what about if you're at increased risk?  We also offer information on that.  Say you've had a personal history of precancerous polyps or adenomatous polyps.  It depends on how many you have had and the size of those polyps.  If you had only one or two and it was a small polyp and it didn't have any significant dysplasia or precancerous changes, you can go five years before your next colonoscopy once that polyp has been removed.  But say you had 10 or more in a single exam, you're not gonna even get to go three years.  And if you had a sessile adenoma which is a flat adenoma and commonly those are not completely removed, we want to see you back in two to six months largely because it isn't able to be completely removed in that initial setting so we need to go back in, reassess it and possibly remove more. 

So, that's for increased risk but then what about, oh, here's another page of increased risk if you have a personal history of colon cancer or if you have a family history of colon cancer.  We're gonna start you earlier if your first degree relative mother or father, sister, brother had colon cancer before the age of 60.  We're gonna start you earlier and we're gonna do your colonoscopy more frequently every five years instead of every 10 years.  High risk are those individuals who say have a genetic predisposition to FAP, familial adenomatous polyposis, or HNPCC, hereditary nonpolyposis colon cancer.  Those are two genetic predispositions for colon cancer.  You can see these individuals we start very, very early in the teens, in the 20s and maybe you're doing colonoscopies every year on those individuals.  These are very, very high risk.  Similar for inflammatory bowel disease, we're gonna start at a certain interval of time after the disease was diagnosed and do it very frequently.  So you can see how we have laid out different recommendations based on your level of risk.  I just select a colon cancer but we actually probably by the end of November will have about 9 different cancer screening guidelines.  They are on the internet for you to see with information about screening for individuals at average, increased or high-risk, so I hope you will take advantage of that.  Review it and then go in and talk to your doctor about what screening tests are appropriate for you.  I want to close--I can't ever talk about cancer screening without talking about the Cancer Prevention Center at MD Anderson.  It's a very unique entity at a cancer center.  This is an entity about seeing patients who don't have cancer but trying to find cancer early, prevent cancer, and do research for both of those.  We offer risk assessment services including genetic testing, wellness education, nutrition counseling, tobacco cessation services.  We're gonna have an exercise physiologist that will talk to you about exercise prescriptions, preventive therapy.  There are now some medications that are FDA approved to reduce an individual's risk of getting cancer so we can talk to you about that if you're appropriate for that.  We offer screening services and I've listed a bunch of them here.  And for a few cancers like breast and skin, we also offer diagnostic services, a woman who has an abnormal mammogram or breast exam or if an individual has a skin lesion that they're concerned as cancer.  Here's the information on how you access our services.  You can call us at (713) 745-8040 or you can go online and fill out an online form and come in and talk to us about what is your risk of developing cancer and what kind of personalized cancer prevention program would we lay out for you.  At MD Anderson's Cancer Prevention Center we're trying to make cancer prevention a reality.  I thank you for your time and attention.

[ Applause ]

>> We can probably take one, two questions for Therese.  Dr. Bevers, go ahead.

>> In your [inaudible] that you say that your life expectancy is less than [inaudible] what are the numbers now for life expectancy?

>> You know that's a good question and I don't know that information at the top of my head.  We actually have that information but I'm sorry I can't discuss it.  It is significantly higher than it had been in the past but I can't recall the exact number so I don't want to lay one out.  Yes sir?

>> The process for getting into the [inaudible]
>> Yes.

>> It is long drawn out or is it [inaudible] you can be here at two or three days [inaudible].

>> Generally, yes we can.  We have openings. Now, I always like to preface it with the information about.  We're going to try to schedule you at an appropriate time such that your insurance or Medicare will cover it.  So say that you're a gentleman wanting to come in for prostate screening and you had your last prostate screening last November.  Well, we're gonna actually try to not schedule you 'til November because Medicare will pay for it until then and so while maybe I have an opening in the next few days, I know I have openings next week, you may not get an appointment until November and that so that we can try to make sure that your visit is paid for.  So, we're gonna try to align it with what's appropriate. 

Yes ma'am? [ Inaudible Remark ]
>> Yes.
[ Inaudible Remark ]

>> Typically, what we ask is that you get a consult from your doctor to be sent over.  Largely, again, we want to make sure that your oncologist feels it's appropriate for you to undergo cancer screening at that time and there's a number of variables of that not just, you know, how well is your cancer treatment going, but also sometimes cancer treatments can make you a little bit more vulnerable and like, say immunocompromised and we don't want to be doing some testing like Pap smears or colonoscopy in an immunocompromised individual.  So we want to wait 'til they're passed that.  And so that's why we want you're oncologist involved.  One last question here.  Okay.

>> One more.

>> Okay.  Yes sir?

>> I started in 2003 with the SELECT program.

>> Yeah, that was one of our prostate-- [ Inaudible Remark ]
>> Yes.
>> It's so difficult to get in here this morning.
>> I'm sorry.
>> [Inaudible] your screening program will be done here [inaudible]
>> It's up at the Cancer Prevention Building and that's where you were going for the SELECT and SELECT was our prostate cancer--
>> Sorry.
>> Okay, it was our prostate cancer chemoprevention trial.  And we do have trials that we have to offer individuals through the Cancer Prevention Center to try to find ways to reduce a person's chance of getting cancer or to find cancer early.

>> Alright.  Thank you.

>> Thank you very much.
>> Thanks Therese that was excellent-- [ Applause ]

>> Yeah.  That was excellent.